Ultrasound Differentiation of Twins with Discordant Congenital Diaphragmatic Hernia in the Delivery Room

Most infants with prenatally diagnosed congenital diaphragmatic hernia (CDH) are intubated rapidly after birth to optimize oxygenation and ventilation while avoiding abdominal distention and high mean airway pressures. A twin pregnancy complicated by one twin with a CDH diagnosis is a rare event and is associated with preterm delivery and low birth weight compared to singletons with CDH. In rare cases of discordant CDH in twin pregnancies with an absence of external distinguishing features (similar weights, fetal presentation, and sex), it may be difficult to quickly determine which twin has CDH in the delivery room (DR), raising ambiguity about the best management of both infants. This case describes the successful use of ultrasound (US) in the DR to rapidly diagnose the presence or absence of CDH in discordant twins. By developing a resuscitation algorithm and using in situ simulations prior to delivery, the twin with CDH was rapidly identified, intubated, and transported to the neonatal intensive care unit (NICU) for further management. The twin without CDH received routine care and was transferred to the well-baby nursery. Interprofessional planning and simulation may be used to design a safe resuscitation plan incorporating US diagnosis of diaphragmatic anomalies into the Neonatal Resuscitation Program (NRP) algorithm.